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1. Proposed Insured – Please Print 2. Date of Birth 3. Height – in shoes 4. Weight– in clothes
Date Month Year
…………………..cm. …………………….Kg.
Address: Contact No. (Home) Contact No. (business)
I have read the above statements and answers and they are complete and true to the best of my knowledge and belief and are in continuation of and form part of my
application for insurance to ………………………………………… Dated this …………………… day of …………………….. 20 …………….
…………………………………………………. ……………………………………………..
MEDICAL EXAMINER PROPOSED INSURED
AUTHORIZED FORM
(b) WEIGHT in ordinary clothes …………. Kilograms WEIGHED? ……. D. IS MURMUR TRANSMITTED? …………………. WHERE? ………….
RATE
GENERAL COMMENTS:
11 SKIN, LYMPH NODES, BREASTS, MUSCLES, BONES or [ ] [ ]
JOINTS?
13 HAVE YOU REASON TO BELIEVE THERE IS ANYTHING UNFAVOURABLE ABOUT THE HABITS IN REGARD TO ALCOHOL OR DRUGS?
14 DO YOU KNOW OF ANY SIGNIFICANT MEDICAL HISTORY OR INFORMATION NOT ALREADY MENTIONED ON EITHER YES NO
SIDE OF THIS FORM? [ ] [ ]
Comment here or by confidential letter to Medical Consultant, GUARDIAN GENERAL INSURANCE LIMITED
15 urinalysis – results of Examiner’s Urinalysis – SUGAR PRESENT? …………... PROTEIN PRESENT? …………………. SPECIFY GRAVITY ………………
A microscopic urinalysis is required if:
(i) Abnormality of urine noted by examiner or if there is a history of abnormality. (ii) Blood pressure is elevated.
I have carefully examined …………………………………………………. This ……………. Day of ……………………….. 20 ……… at ………….. O’clock A.M. [ ]
Examination was made in private at [ ] my office [ ] residence of Proposed Insured P.M. [ ]
[ ] place of business of Proposed Insured
………………………………………………………….
Medical Examiner’s Signature